Chronic Venous Diseases: How to Improve Your Patient

Quality of Life

Patrianef, MD

General Surgeon

Vascular and Endovascular Consultant Surgeon

Surgery Department, FMUI-CM Hospital

Jakarta - 2014

Daftar Riwayat Hidup

Dokter Umum : FK Unand

Spesialis Bedah : FK Unand

Subspesialis Vaskular dan Endovaskular :

FKUI/RSCM

Interventional Vascular : UKM/Hospital Universiti

Kebangsaan Malaysia.

Pekerjaan : Staf Departemen Bedah

FKUI/RSCM

Jabatan : Sekjen Perhimpunan Spesialis

Bedah Vaskular dan Endovaskular Indonesia

Varicose Vein

Chronic Venous Disease

(CVD)-Definition

“Chronic Venous Disease (CVD) is defined

as an abnormally functioning venous

system due to venous valvular

incompetence with or without associated

venous outflow obstruction, which may

affect the superficial venous system, the

deep venous system, or both.”

Each situation

Each diseasehas different perspectives

Evaluation of:

Symptoms

◦ Consumption of analgesic – Pain

◦ Visual scale – Pain

◦ Numeric scale – Pain, Leg heaviness, Cramps, Swelling, Heat sensation

◦ Reduction in the number of patients presenting a specific symptom

Signs

◦ Edema – Perimeter (Leg-o-meter); Volume (Water displacement)

◦ Leg Ulcer – Size + Time to Healing

Physicians’ Perspective

1 - Eklof B et al. J Vasc Surg 2009;49:498-501; 2 - Eklof B. et al. J Vasc Surg 2004;40:1248-1252.

Signs 1,2Symptoms 1

• C0: No visible signs

• C1: Telangiectasia, reticular veins

• C2: Varicose veins

• C3: Edema

• C4: Skin changes

C4a: pigmentation, eczema,

C4b: lipodermatosclerosis,

atrophie blanche.

• C5: Healed Venous ulcer

• C6: Active Venous ulcer

• Tingling

• Aching, Burning

• Pain

• Muscle cramps, Swelling

• Throbbing

• Heaviness

• Itching skin

• Restless legs

• Leg-tiredness

• Fatigue

Chronic venous disease-related symptomsand signs are clearly described(from consensus documents)

Con

clu

sion

Clinical aspects

◦ Quantitative measurement tools

Pain assessment tool Remarks

Analgesic consumptionOnly practitioner-reported data are

reliable

10-cm visual analogue scale (VAS) Good reproducibility

Numerical scale (usually from 0 to 5) Good reproducibility

Others:

McGill Pain Questionnaire

Brief Pain Inventory

Multidimensional Pain Inventory

Impractical in routine

Close to a quality-of-life scale

Skewed towards back pain

Adapted from Allaert FA. Medicographia 2006;28:137-140

Symptoms

Physicians’ Perspective

◦ Assessing treatment effect on signs:

Which end points?

End point Need for a consensus about

EdemaHow great a decrease in leg volume constitutes a clinical

improvement?

Varicose veinsCosmetic satisfaction of patients? Absence of pain?

Absence of reflux? No recurrence? Quality of life?

Cost effectiveness?

Venous ulcer

Complete re-epithelization of the wound? Time to healing?

Ability to walk without reopening of the wound? Frequency

of dressing change? Frequency of admission to hospital?

Signs

Physicians’ Perspective

Instrument Purpose Remarks

CEAP classification,

the AVF Ad-hoc Committee, 1995,

2004

For patient’s description onlyNot for scoring

(not sensitive to changes)

• Venous Clinical

Severity Score (VCSS)

• Venous Disability

Score (VDS)

• Venous Segmental

Disease Score (VSDS)

Rutherford, 2000

• To assess changes over time or

in response to therapy

f

• To assess the ability to work an

8-hour day with or without a

“support device”

• To generate a grade based on

reflux or obstruction

• Imperfect tool for

evaluation of the early

stages

• Daily activities not taken

into consideration

f

• Arbitrary and difficult to

grade

Adapted from Vasquez MA. In press

◦ From the CEAP to its adjuncts

Signs

Physicians’ Perspective

Patient’s Perspective

Type of instruments:

Preference about care received

Health behaviours

Subjective symptoms

Patient satisfaction

Health related quality of life

PRO – Instruments that measures perceived health outcomes or

endpoints assessed by patients reports (questionnaires)

Quality of Life (QoL)

WHO definition

Multidimensional concept, including:

Physical

Psychological

Social

Patient perception about disease (subjective state of health)

Information – burden illness

“The product of the interplay between social, health, economic and

environmental conditions which affect human and social development”

Alliot-Launois, 2003; Pitsch, 2008; Kahn, 2008; Vasquez , 2008

Quality of Life (QoL)

Pitsch, 2008; Vasquez , 2008; Alliot-Launois, 2003

Generic instruments:

Nottingham Health Profile (NHP)

Short Form 36 Health Survey (SF-36)

Disease-specific instruments

Charing Cross Venous Ulceration Questionnaire (CXVUQ)

Aberdeen Varicose Vein Questionnaire (AVVQ)

Venous Insufficiency Epidemiological and Economic Study (VEINES)

Chronic Venous Insufficiency Questionnaire (CIVIQ)

Evaluation:

Symptoms and quality of life

The % of symptomatic patients increases with increasing CEAP

class.1-3

There is a significant association between increasing CEAP

class and reduced quality of life (QOL),4 even after adjustment

for confounding variables.5

The QOL impairment associated with CVD is equal to the QOL

impairment associated with other chronic and severe diseases

(C3=cancer and diabetes6; C5-C6= heart failure7).

1. Rabe E. Int Angiol. 2012;31:105-15. - 2. Chiesa R. J Vasc Surg. 2007; 46:322-330.

3. Carpentier P. J Vasc Surg. 2003; 37:827-833. - 4. Franks PJ. Qual Life Res. 2001;10:693-700.

5. Kahn Sr. J Vasc Surg. 2004;39:823-828. - 6. Andreozzi GM et al. Int Angiol. 2005;24:272-277.

7. Ware JE. 1994. New England Medical Center.

Burden of Chronic Venous

Disease

CVD (C1 to C6) affects 75 % of adults in the USA1 and around 64% worldwide.2

CVI (C3 to C6) affects 16% of adults in the USA1 and 24% worldwide.2

Venous ulcers (C6) affect 2.5 million patients/year in the USA.3

70% of venous ulcers recur within 5 years of healing.4

1- Passman MA. J Vasc Surg 2011;54:2S-9S 2- Rabe E. Int Angiol 2012;31:105-115.

3- Eklof B. J Vasc Surg 2004;40:1248-1252. 4- Callam MJ. BMJ. 1987;294:1389-1391.

Epidemiology of chronic

venous disease

CEAP clinicalclass (%

individuals)

USA1 Germany2 Worldwide3

C0 26 10 36

C1 33 59 22

C2 24 14 18

C3 9 13 15

C4 7 3 7

C5 0.5 0.6 1.4

C6 0.2 0.1 0.6

1- McLafferty RB et al. J Vasc Surg. 2008;48:394-399.

2- Rabe E et al. Phlebologie. 2003;32:1-14.

3- Rabe E et al. Int Angiol. 2012;31:105-115.

In the USA, more than 50% of adults present with telangiectases or varices

(not adjusted for age, gender, or BMI)

Epidemiology of chronic

venous disease

CEAP clinicalclass (%

individuals)

USA1 Germany2 Worldwide3

C0 26 10 36

C1 33 59 22

C2 24 14 18

C3 9 13 15

C4 7 3 7

C5 0.5 0.6 1.4

C6 0.2 0.1 0.6

In the USA, more than 50% of adults present with telangiectases or varices

(not adjusted for age, gender, or BMI)

1- McLafferty RB et al. J Vasc Surg. 2008;48:394-399.

2- Rabe E et al. Phlebologie. 2003;32:1-14.

3- Rabe E et al. Int Angiol. 2012;31:105-115.

The frequency of varicose

veins increases with older age

1- Abramson JH et al. J Epidemiol Community Health. 1981; 35: 213-217.

2- Coon WW et al. Circulation 1973 ; 48:839-846.

The prevalence of venous

ulcer also increases with age

Cornwall JV et al. Br J Surg. 1986;73:693-696.

Socioeconomic aspects

of chronic venous disease Overall annual costs:

900 million € in Western Europe (2% of health care budget)1

Equivalent to 2.5 billion € in the USA

Greater than the amount spent for treatment of arterial disease

Annual loss of work days:

2 million work days lost due to venous ulcers in the USA2

4 million work days lost due chronic venous disease (C1-C6) in France

Ranked 14th for work absenteeism in Brazil

Cost for loss of work days varies between 270 million € (Germany), 320

million € (France), and 3 billion USD per year in the USA2

CVD is progressive, increases with age, and has a propensity to recur.

This further increases costs.

1- Ruckley CV. Angiology. 1997;48:67-9. 2- McGuckin M. Am J Surg. 2002;183:132-137.

Etiology

Reflux 80%

Venous obstruction 18-28%

Resultant edema and skin changes =

Postthrombotic syndrome

Muscle Pump Dysfunction

Risk factors

Age: Aging causes wear and tear. Eventually,

that wear causes the valves to malfunction.

Sex: Women > Men. Hormonal changes during

pregnancy or menopause. Progesterone

relaxes venous walls. HRT / OCP may increase

the risk of varicose veins.

Genetics

Obesity: Increases venous HTN.

Standing for long periods of time. Prolonged

immobile standing impairs venous return.Fowkes, FG, Lee, AJ, Evans, CJ, et al. Lifestyle risk factors for lower limb venous reflux in the general population: Edinburgh Vein Study. Int J

Epidemiol 2001; 30:846.

Sadick, NS. Predisposing factors of varicose and telangiectatic leg veins. J Dermatol Surg Oncol 1992; 18:883.

Iannuzzi, A, Panico, S, Ciardullo, AV, et al. Varicose veins of the lower limbs and venous capacitance in postmenopausal women: relationship with

obesity. J Vasc Surg 2002; 36:965.

Evans, CJ, Fowkes, FG, Hajivassiliou, CA, et al. Epidemiology of varicose veins. A review. Int Angiol 1994; 13:263.

Incidence

25-50% of adult

women

15-30% of adult

men

1-2% with Active or

Healed Ulceration

Patrick H. Carpentier, Hildegard R. Maricq, Christine Biro, Claire O. Poncot-Makinen, Alain Franco, Prevalence, risk factors, and clinical patterns of chronic venous disorders of lower limbs: A population-based study in France, Journal of Vascular Surgery, Volume 40, Issue 4, October 2004, Pages 650-659, ISSN 0741-5214, DOI: 10.1016/j.jvs.2004.07.025. Coon WW, Willis PW III, Keller JB. Venous thromboembolism and other venous disease in the Tecumseh community health study. Circulation 1973; 48: 839–846.Franks PJ, Wright DD, Moffatt CJ, Stirling J, Fletcher AE, Bulpitt CJ et al. Prevalence of venous disease: a community study in west London. Eur J Surg 1992; 158: 143–147.Bradbury A, Evans C, Allan P, Lee A, Ruckley CV, Fowkes FG. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. BMJ 1999; 318: 353–356

Chronic venous disease

Most common vascular disorder

3 Billion US dollars spent a year for

treatment

3 % of the total Heath care Budget

2 million USA work days lost per year

Class C0s:

Symptoms without visible or palpable signs of venous disease

Class C1a,s:

Telangiectasias or reticular veins

a = asymptomatic

s = symptomatic

Class C2a,s: Varicose veins

Class C3a,s: Edema

Class C4a,s:Skin changes ascribed to venous disease,eg, pigmentation, venous eczema, lipodermatosclerosis

Class C5a,s: Skin changes with healed ulceration

Class C6a,s: Skin changes with active ulceration

The CEAP* classification –

Identification of CVD patient profiles8

8. Allegra C, Antignani PL, Bergan J, Carpentier P, et al. J Vasc Surg. 2003;37:129-313.* CEAP: Clinical, Etiological, Anatomical, Pathophysiological.

C1

C4

C2 C3

C6 C5

MACRO circulation MICRO circulation

Progression of chronic venous disease:

venous hypertension is key

Adapted from Bergan JJ et al. N Engl J Med. 2006;355:488-498, and from Eberhardt RT et al. Circulation. 2005; 111:2398-2409

SymptomsSymptomsC0s Symptoms Symptoms

Varicose Veins (C2)Reflux Edema (C3)

Skin Changes (C4)

Vein wall remodeling

Valve damage

Capillary leakage

Capillary damage

Venous Ulcer (C5,6)

Altered patterns of blood flow,

Change in shear stress

Genetic

predisposition,

obesity, pregnancy,

..

Environmental

factors repeated

over timeChronic inflammation in vein wall and valve

Remodeling in venous wall and valves

Valve failure, reflux

Chronic hypertension

Adapted from JJ Bergan et al. N Engl J Med 2006 355:488-498

Shear stress dependent leukocyte-endothelial interaction

Activation

of

C nociceptors

Pain

Venous hypertension is linked to

venous inflammation

“ Treatment to inhibit inflammation may offer the greatest

opportunity to prevent disease-related complications.

Drugs can attenuate various elements of the inflammatory cascade,

particularly the leukocyte–endothelium interactions that are

important in many aspects of the disease »

Increased Capillary Permeability

Adapted from Schmid-Schönbein G N. The Vein Book 2007 Academic Press

Hypertension is transmitted to capillaries

EDEMA

SKIN

CHANGES

Lymphatic overload

Adapted from Perrin M, Ramelet AA. Eur J Vasc Endovasc Surg. 2011; 41:117-125.

Lymphatic drainage is disturbed

Pitting edema

(Lymphedema)

Examination

1. Valsava test and The Trendelenburg test Used to assess the competence of SFJ

2. Tourniquet test Similar as trendelenburg test, uses a tourniquet

Assess perforator vein

3. Perthes Test Indicated deep venous incompetence.

This is a painful and rarely used test.

All of these examination are rarely used, only when duplex scanning or dopplerare not available

J Vasc Surg 2011;53:2s-

48s

Non invasive

measurement

Ultrasound 1980, gold standard

method instead of phlebography

1990, color dopplerimproved the reliability

Diagnostic and interventional guided treatment

Photophletysmography Ambulatory venous

pressure measurement

Van der Bremmer et al. Ann Vasc Surg 2010; 24: 426-432

J Vasc Surg 2011;53:2s-

48s

Therapy

Education

Compression

Drugs

Physioterapy

TREATMENT

Limit the disease

progression

Lifestyle changes

Compression stocking is

the basic and the most

used ( Grade I A,B & Grade 2 C)

Exercise

Conservative

Leopardi et al. Systematic Review of Treatments for Varicose Veins. Ann Vasc Surg 2009

Medicine

Venoactive drugs ( Grade 2 B)

Pentoxiphylline

Saponins

Flavonoids: rutoside,

diosmin,

hesperidin,

MPFF

Synthetic Calcium dobesilate, naftazone, benzarone

Reduce edema and restless leg

syndrome, improve healing of venous

ulcer

J Vasc Surg 2011;53:2s-

48s

The most

effective

venoactive

drugs

according to

Cohrane

review

Quality-of-life improvement

parallels symptom improvement

Parameter

N=3995

Change in

symptoms

Patients with symptom

improvement, N (%)

Increase in CIVIQ score

between Day 0 and Day 180

Sensation of swelling

Improved* 2134 (69) 21.1 + 16.8

Heaviness Improved* 2778 (74) 20.1 + 16.2

Cramps Improved* 2189 (79) 21.1 + 16.4

Pain

Improved§ 1560 (80) 23.8 + 16.2

Very much improved**

442 (23) 29.2 + 16.9

* Improved: decrease of one class on 5-point scale. §Improved pain: decrease of 2.5 to 5 cm on VAS.** Very much impoved pain: decrease of ≥5 cm on VAS.

Launois R, Mansilha A et al. Eur J Vasc Endovasc Surg. 2010;40:783-789.

In C0s to C4s patients

ReferenceRegimen

(nb of enrolled patients)

Changes in

PainFunctional

discomfort

Sensation

of swelling

Leg

heaviness

Chassignolle

et al. 1Daflon 500 mg (18)

vs placebo (18)

Not

assessed

Not

assessed

Gilly

et al. 2Daflon 500 mg (76)

vs placebo (74)

Cospite

et al. 3Daflon 500 mg (43)

vs single diosmin (45)

Not

assessedNS

NS, not significant; + P<.05; ++ P<.01; +++ P<.001 Daflon 500 mg vs comparator

1. Chassignolle J-F et al. J Int Med 1987;99 (Suppl.):32-7. - 2. Gilly R et al. Phlebology 1994;9 (2): 67-70.

3. Cospite M et al. Int Angiol 1989; 8 (4 suppl): 61-65.

Significant improvement of

venous symptoms in well-designed trials

Significant reduction of leg pain

associated with venous ulcer%

Pat

ien

ts w

ith

ou

t p

ain

N=459 * P =.0023 **P <.001

* **

**

2328

37

Lok C. Abstract presented at the 7th meeting of the EVF, London, UK, 29th June- 1st July, 2006

Significant reduction of leg edema

which is often associated with venous pain

Population size

N=463

N=165

N=90

N=45

N=497

Allaert FA. Int Angiol 2012;31:310-5.

Venous pain is a nociceptiveresponse

to venous inflammation and therefore difficult to

express Heaviness Pain, aching Sensation of swelling Burning Night cramps Tingling Itching Restless legs Leg tiredness, fatigue

1. Eklof B et al. J Vasc Surg. 2009;49:498-501. - 2. Strigo IA et al. Pain. 2002;97:235-246.

3. Vital A et al. Angiology. 2010;19:73-77.

Nociceptive response

via C-fibers 3

Probably express

the same symptom 1

=

Diffuse pain 2

Vein-specific anti-

inflammatory action

Adapted from Shoab SS et al. Eur J Vasc Endovasc Surg .1999;17:313-318.

Leukocyte

ICAM-1

Daflon 500

mgDaflon 500 mg

CD11b/CD18

VLA-4

VCAM-1

Adapted from Coleridge Smith P. In Ruckley, Fowkes, Bradbury, eds. London, UK: Springer-Verlag; 1999:51-70.

Damage induced by leukocyte migration at the level

of the venous valves is present at the onset of the disease

The leukocyte – A central role in

the pathogenesis of CVD

Venoactive Drugs: Action

Macrocirculation: Increase venous tone,

attenuate leucocyte-endothelial

interaction

Microcirculation: Increase capillary

resistance and reduce capillary

filtration, increase lymphatic drainage,

reduce inflammation, decrease blood

viscosity.

Document developed under the auspices

of:

The European Venous Forum

The International Union of Angiology

The Cardiovascular Disease Educational

and Research Trust, UK

L’Union Internationale de Phlébologie

On the initiative of the European Venous

Forum

International Guidelines

for management of CVD (2013)

Updated recommendations

for VADs according to the GRADE

systemIndication Venoactive drug Recommen

dation

Quality of

evidence

Code

Relief of symptoms in C0s to

C4s patients, when no other

anatomical lesions and/or

pathophysiological anomalies

are present

• MPFF (Daflon 500)

• Non micronized diosmins

• Rutins (Venoruton)

• Calcium dob. (Doxium)

• Horse chestnut

• Ruscus extracts

• Strong

• Weak

•Weak

•Weak

•Weak

• Weak

•Moderate

•Poor

•Moderate

•Moderate

• Low

• Low

1B

2C

2B

2B

2B

2B

Healing of primary ulcer, as

an adjunct to local therapy and

compressive or/and operative

treatment

(Coleridge Smith, 2009)

• MPFF (Daflon 500) • Strong •Moderate 1B

To be published by end 2013.

Treatment

Sclerotherapy (Grade1 B) Small non-saphenous varicose veins

(less than 5 mm),

Perforator veins

Residual or recurrent varicosities following surgery

Telangiectasia

Reticular veins

To initiate Inflammation,

Occlusion and

Scarring

US guided

Foam sclerotherapy ( Grade 1 B )

Catheter directed

Complication: blistering and ulceration 7.1%, phlebitis 15.4%, staining 7.7%

Leopardi et al. Systematic Review of Treatments for Varicose Veins. Ann Vasc Surg 2009

Surface /skin laser therapy

Telangiectasias, reticular veins,

small varicose veins <5mm

Treatment

Ambulatory

phlebectomy

( Grade 1 B)

For larger veins

Below SFJ and

SPJ

Not including the

GSV or SSV

Without reflux

Complication:

blistering 31%,

phlebitis 12%,

hematoma

Junction ligation

with or without

vein stripping

When GSV and

SSV have reflux

Ligation alone

high recurrence

Ligation and

stripping

treatment of choice ( Grade 2 B)

Leopardi et al. Systematic Review of Treatments for Varicose Veins. Ann Vasc Surg 2009

TIPP-Transilluminated

powered phlebectomy ( Grade 2

C)

“LIPOSUCTION OF

VEIN”

Safe and effective for

vein excision

Complication: cellulitis

2.2%; abscess 0.4%;

hematoma 3.4%;

residual varicose 1.1%;

cutaneous nerve

damage 2.2%, seroma

2.9%

The Vein Book 2007

Kiw JW, Surgery Today

2013;43:62-66

Subfascial endoscopic perforator vein

ligation (SEPS) ( grade 2 C)

Refractory symptoms, ulceration, recurrent ulceration.

Perforators divided electrocautery, harmonic scalpel or clipped.

1140 limbs overall ulcer healing in 88%

Kalra, M, Gloviczki, P. Surgical treatment of venous ulcers: role of subfascial endoscopic perforator vein ligation. Surg Clin North Am 2003; 83:671.

Treatment

RFA and EVLT ( Grade 1 B)

Heat-generating laser fiber via

catheter

Heat source: Laser or radiofrequency

Endothelial and vessel wall damage

J Vasc Surg

2011;53:2s-48s

EVLT

KONDISI AWAL PASIEN DENGAN CVITINDAKAN EVLT

MAPPING

2 HARI POST EVLA

7 HARI POST EVLA3 BULAN POST

EVLA

Mechanicochemical

endovenous ablation

A new alternative treatment

Endovenous mechanical and chemical

sclerotherapy

Technical success rate: initial 100%;

after 1 year 94%

No major complication

ESVS 2012.jejvs.2012.12.004

Van Eekeren et al. J Endovasc Ther 2011;18:328-334

Take Home Messages

The mechanisms resulting in venous pain involve:

The presence of nerve structures (C-fibers) in the vein wall and perivenous space close to the capillaries

Local inflammation mediated by activated leukocytes

MPFF inhibits:

Leukocyte activation

Subsequent venous inflammation

May provide an explanation for MPFF’s benefits on venous pain and quality of life

Practical use

Treatment of symptoms and edema likely to be

of venous origin.1

May be combined with sclerotherapy, endovenous

treatment or open surgery for the treatment of

varicose veins.2-4

Adjunctive treatment in venous leg ulcer (VLU)

healing and for relief of VLU-associated symptoms.5

1. Lyseng-Williamson K et al. Drugs. 2003;63:71-100 - 2. Veverkova L et al. Phlebolymphology. 2006;

13:195-201 - 3. Pokrovsky AV et al. Angiol Sosus Khir. 2007; 3:47-55 - 4. Cazaubon M et al. Angiologie.

2011;15: 554-560 - 5. Coleridge-Smith P et al. Eur J Vasc Endovasc Surg. 2005;30:198-208.

Suggestion

Varicose:

phlebectomy

GSV varices not related to reflux

sclerotherapy

GSV plus reflux surgery or foam

sclerotherapy

Ligation without stripping is more effective

than phlebectomy alone.

EVLT and RFA are better than surgery in regard

to QOL, return to work etc

EVLT and RFA are considered as an effective

alternative to surgery, as safe as surgery with

long-term safety supported by case evidence.

Healthy leg is our aim

Varicose is not just a

cosmetic problem, but

….

Varicose is a disease

entity which can reduce

the QOL

Definition of Vascular Surgery

Society for Vascular Surgery

is the specialty that deals with the

diagnosis and management of disorders

of the arterial, venous, and lymphatic

systems, exclusive of intracardiac and

intracranial vessels.

Specialist

Vascular surgeon

› Is a vascular specialist who performs traditional open

surgery and endovascular intervention and is

competent to treat vascular diseases with non

interventional and non surgical means

› Capable to handle patient from diagnostic until

treatment

› Competency in Surgery :

Able to overcome the complications

Guidelines for hospital privileges in vascular and endovascular

surgery: Recommendations of the Society for Vascular Surgery J

Vasc Surg. 2008 ;47(1):1-5

One of 14 Specialties in Surgery

http://www.facs.org/medicalstudents/an

swer1.html

Spesialis Bedah Vaskular

http://www.surgeons.org/surgical-specialties/

76

Mr T,50 yo central vein

occlusion

Post Plasty

2013

EVAR

Transformation of Vascular

Surgery in Indonesia

Open Surgery

PPDSp2 vaskuler dan

endovaskuler

Informasi

Sekretariat Divisi Bedah Vaskuler dan

Endovaskuler FKUI/RSCM

Gedung A, Public Wing, Lantai 3. Rumah Sakit

Cipto Mangunkusumo

Jl.Diponegoro no 71 Jakarta Pusat

Telepon/Fax :021-3910487

Email:dvascsurgery@yahoo.com

Kontak person : Okwina Minarni

Thank You